Laserfiche WebLink
_ f SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: �V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76 7&1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to; the San, Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made 'in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Ru and Regulations of the San Joaquin Local Health District.} <br /> JOB ADDRESS/LOCAT N (x�?�G�_ Ct4 1`� CENSUS TRACT <br /> Owner's Name t Phone <br /> Address . za� (.�r City <br /> 9 <br /> Contractor's Name �'(.7 -License IOZ7 one <br /> TYPE..OF WORK _(Check) : NEW .WELL __ DEEPEN-/T CONDITION. /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other Z /. <br /> DIST CE TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER -- <br /> tJ PROPERTY-LINE -• PRIVATE DOMESTIC WELL PUBLIC.DOMESTIC WELL <br /> INTENDED USE TYPE,;OF WELL CONSTRUCTION ,SPECIFIC IONS \. <br /> ,0' Industrial able Tool""` Dia.-of:We11 Excavation - ; <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - L r-ftgation Gravel Pack Depth of Grout Seal \� <br /> Cathodic Protection 1 . Rotary Type of Grout '�--- <br /> Disposal Other Other Information <br /> ' Geophysical Surf ,Seal Ins 11 By: <br /> 6 1 <br /> PUMP' INSTALLATION: Contractor ,(JAL ; <br /> F.. Type of Pump r H.P. Q <br /> PUMP REPLACEMENT �z / / State Work bone.q <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF' WELL: ` Well Diameter Approximate Depth j <br /> -- <br /> Describe Material and Procedure <br /> ' f <br /> I hereby, agree to comply with #all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to ,or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work ori a'new well;I will furnish the San'J.oaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify'them-before-putting the-.well ,iri use. The above <br /> information is true to the bp'sp of my knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO GR I -AND %A FIN NSP IOI9. <br /> SIGNED TITLE 69 / <br /> ARA T' PLAN ON REVERSE SIDE) <br /> OR DEPARTMENT USE ONLY, r <br /> PHASE I } <br /> APPLICATION ACCEPTED BY l x DATE <br /> ADDITIONAL COMMENTS: . i <br /> PHASE II GROUT.INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE Z-+� INSPECTION BY DATEeh <br /> E H 1426 Rev. 1-74 3/76 2M <br />